Getting Your Medical Records (Script 421)

From Clicklaw Wikibooks

The Dial-A-Law library is prepared by lawyers and gives practical information on many areas of law in British Columbia. This script gives information only, not legal advice. If you have a legal problem or need legal advice, you should speak to a lawyer. For the name of a lawyer to consult, call the Lawyer Referral Service at 604.687.3221 in the lower mainland or 1.800.663.1919 elsewhere in British Columbia.

Who do medical records belong to?

Many people think that their medical records are their own property, and that if they want to see them, they just have to ask. That’s only partly true. Your medical records actually belong to the doctor, hospital, or other place that made them, not to you. That’s also true for dental records and nursing home records. But the information in the medical records belongs to you. And normally, you have a right to see that information. The records should include any treatment or procedure that went wrong because courts have said that doctors have a legal duty to give patients that type of information.

Medical records that your doctor keeps

To see your medical records kept by your doctor, just ask the doctor to see them. Your doctor has a privacy officer—usually the doctor—to deal with the request. Under the BC Personal Information Protection Act, you have a right to see the information. And the doctor will normally show you the records or give you the information in them. You can also ask for a copy of your records, but the doctor may charge you a fee (set by the BC Medical Association in its fee guide to copy them because medical insurance does not pay for this. You could also ask to take a picture of the records with your phone—this option is quite new so doctors may not have a position on it yet.

Doctors have to keep medical records for at least 16 years from the last entry in the record, or from when the patient reaches the age of majority (19 years old in BC)—whichever comes later.

Accuracy and privacy of doctor records—the College requires all doctors to keep and securely store accurate records for every patient, with the date and type of every service provided to them. And the Personal Information Protection Act requires doctors to make sure the information in your medical records is accurate and to keep it private. If you think the doctor made a mistake in your medical records, you can ask them to fix it. The doctor has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.

Rarely, a doctor may refuse to give you the information in your medical record, thinking that it could cause immediate or grave harm to your safety or to your physical or mental health. If that happens, and you can’t solve the problem with your doctor, contact the College of Physicians and Surgeons of BC. The College’s Complaints Department may be able to help you. The College phone number is 604.733.7758 in Vancouver and 1.800.461.3008 elsewhere in BC.

If you still can’t solve the problem, contact the Information & Privacy Commissioner for BC. The Commissioner’s phone number in Victoria is 250.387.5629 and the email is info@oipc.bc.ca. Outside of Victoria, call Enquiry BC and ask for the Office of the Information & Privacy Commissioner. To reach Enquiry BC, call 604.660.2421 in the lower mainland and 1.800.663.7867 elsewhere in BC.

Lastly, you can see a lawyer for legal advice on what to do.

Medical records that hospitals and other public entities keep

To see your hospital records, contact the medical or health records department of the hospital and ask for their information and privacy office or the person in charge of giving out information. If you make a written request, the hospital has 30 days to respond. Usually, you can see your hospital records and get a copy. The Freedom of Information and Protection of Privacy Act covers records kept by hospitals and other public entities. Check script 235, called “Freedom of Information and Protection of Privacy” for more on this law.

Accuracy and privacy of hospital records—the Freedom of Information and Protection of Privacy Act requires hospitals to make sure the information in your medical records is accurate and to keep it private. This law also gives you the right to ask the hospital to correct any errors or omissions in your records. The hospital has to make a note of your request. But once medical information is recorded, it is not supposed to be destroyed or changed based on a patient’s request.

Hospitals have to keep most medical records for at least 10 years (and some for 6 years) under the Hospital Act Regulation.

If a hospital refuses to let you see your records, it must tell you why. If you disagree with the hospital’s decision, you can ask the Information and Privacy Commissioner for BC to review it.

Lastly, you can see a lawyer for legal advice on what to do.

Are your medical records confidential?

Yes, medical records are normally confidential. Doctors and hospitals must not give them to anyone else, except in certain cases:

Other people who give you medical care, such as specialists, will need your medical records.

If you’re in a lawsuit about your medical history, your lawyer will need your medical records. Usually, doctors and hospitals will copy your medical records to your lawyer if you ask them to.

A court can order your medical records be shown to other people and lawyers in a lawsuit.

If you apply for life or health insurance, the insurance company will often need your medical records before giving you insurance.

Some types of jobs may require medical information. However, potential employers can get your records only if you agree to let them see the records.